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Estimating Total Acetaminophen Burden in LTC Residents with Diabetes
Elderly Orthopedic Patients Transferred to an Intermediate Care Facility in Singapore - A One Year Review Presenting Author: David H. Yong, MBBS, Mmed, Changi General Hospital Author(s): David H. Yong, MBBS, Mmed; and Ivan Ngeo, MBBS Introduction/Objective: The department of geriatric medicine of an acute hospital has been providing regular orthogeriatric services for care of elderly patients with falls and fractures. One of the interventions includes a transfer of selected cases to a new community based step-down ward for optimization of geriatric problems. This 10 bed ward is staffed by senior community family physicians with special training and interest in eldercare and a multidisciplinary team of gerontology-trained nurses and allied health workers. This is a preliminary audit of the outcomes of this ward. Design/Methodology: Retrospective audit, all cases over 12 months (Sept 08-Aug 09).Clinical data obtained from case notes. Analysis by Excel. Results: N580 out of 536 orthogeriatric cases seen (15%); M5 18, F5 62; mean age5 85.6 yrs; Hip fractures 66 (neck of femur fractures 38, trochanteric 28) spine56, pelvis54, hip contusion54. Sixteen (20%) have had previous fractures. Operated cases540. aLOS) in orthopedic wards 9.8d; aLOS in step-down ward 19.7d; total aLOS529.5d Complications in ortho wards: UTI538 (47%), cardiac527(34%) recent stroke520(25%), pneumonia545(56%), delirium522(28%). 28 were on physical restraints, 20 had feeding problems. The Abbreviated Mental Test was impaired in 90% of those done. Transfer reasons: subacute care 48(60%), assessment and rehabilitation 35(43%) and discharge planning 25(32%).1/3 had two or more reasons. Pre-transfer: 32 cases were on antibiotics, 28 had an indwelling catheter, 18 had feeding tube, 18 were on physical or pharmacological restraints whilst 15 needed regular wound management. 36 (44%) had two or more of these problems. New complications in step-down ward: worsening or new infections 50 (63%), bleeding 20 (25%), diarrhea 13, hypotension 8, metabolic problems 10. The most common infections were pneumonia 25% and UTI 20%. 16 cases (20%) had to have a new NG tube inserted. Outcomes: 82 (40%) were able to ambulate; 40 (60%) were discharged back to own home, 12 (15%) to a rehabilitation hospital and 10 (12.5%) to nursing home. Deaths, 12(15%) all had pneumonia as contributory factors with 5 others having a vascular event. Conclusion/Discussion: Orthopaedic cases transferred over to the stepdown ward are frail elderly. Many that were not operated on for fractures had common geriatric conditions like infection, vascular disorders, cognitive impairment, and poor feeding. The major step-down complication was nosocomial infection. 40% regained mobility, 60% went home, 15% to nursing homes. An intermediate care ward staffed by a multidisciplinary team led by family physicians and nurses trained in care of elderly was effective in providing subacute and rehabilitative treatments for elderly orthopedic patients. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.
End of Life Care in the Nursing Home Setting Presenting Author: Petra Flock, MD, MSc, CMD, University of Massachusetts Author(s): Petra Flock, MD, MSc, CMD; and Jill M. Terrien, PhD, APN-BC Introduction/Objective: For this study a cross-sectional mailed survey to explore next of kin’s perspectives on end-of-life care in the nursing home setting was developed. It tested the feasibility of the method in terms of recruitment and response rate, and pilot tested the survey instrument. Decedents who received Hospice services in addition to traditional nursing home care were compared to those who received traditional care alone. Design/Methodology: A postal survey was designed and tested with next of kin of nursing home decedents of three nursing homes, who died between 4/1/07 to 4/1/08. Data collected included: demographics, communication, pain and symptom management, advance directives, hospice utilization and responses to two qualitative questions. Quantitative data was analyzed
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using frequencies, percentages and Pearson chi square statistics. Qualitative data was analyzed by themes. Results: The mailed survey yielded a 70% response rate. Symptom burden was high with more than 70% experiencing pain, agitation, and anxiety; 60% had shortness of breath and depression. Over 88% of next of kin reported good to excellent symptom control, 91% were kept well-informed about the decedent’s condition, and more than 90% were satisfied with medical and nursing care. The vast majority (89%) had advance directives in place. There was no difference in symptom control, communication, level of care or advance directives between the Hospice and traditional care groups. Conclusion/Discussion: Postal survey is a feasible method to explore end of life care in the nursing home setting. In this study, pain, symptom management and communication at the end-of-life in nursing homes was better than nationally reported data 1, 2, 3 irrespective of how that care was provided. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.
Epilepsia Partialis Continua not Amenable to Medical Therapy Presenting Author: Kofi Quist, MD, Montefiore Medical Center Author(s): Kofi K. Quist, MD; and Wanda Horn, MD Introduction/Objective: Epilepsia partialis continua is a type of focal motor epilepsy characterized by persistent clonic movements of a muscle group with repetition at fairly regular intervals every few seconds, continuing for hours, days, weeks, or months without generalization. Design/Methodology: Case. Results: A 78 year old female nursing home resident with past medical history of epilepsy secondary to a right parietal arteriovenous malformation was admitted with left upper extremity clonic movements. Patient had dementia and at baseline was verbal, bedbound, non-ambulatory, and dependant in activities of daily living. Although she was frequently not compliant with her regular epilepsy medications due to paranoid ideations, she had not had a seizure for a significant period of time. Her current medications were phenobarbital and levetiracetam. Physical examination revealed an elderly female who was awake with fluent speech, oriented to person only and with a flat affect. Neurological examination was significant for left facial droop and left hemiparesis. There was increased muscle tone with regular tonic-clonic movements of the left upper extremity. Power was 2/5 on left side and normal on right side in both upper and lower extremities. Sensation was grossly intact to light touch and pinprick. Laboratory data did not reveal any electrolyte abnormalities, but showed subtherapeutic serum level of phenobarbital, and leucocytosis which was attributed to sinusitis. Head CT showed right fronto-parietal encephalomalacia. Patient was evaluated by an epilepsy specialist with an impression of focal seizures. Electroencephalogram was consistent with epilepsia partialis continua. She did not respond to multiple trials of anti-epileptic medications including dilantin, oxcarbazepine, levetiracetam and phenobarbital over a period of seventeen days. The involuntary left upper extremity movements only decreased in intensity when she was heavily sedated with lorazepam but did not completely resolve. After several meetings between the epilepsy specialist, geriatric team and patient’s family, a decision was made to discharge her back to the nursing home with continued left upper extremity clonic movements. Conclusion/Discussion: Epilepsia partialis continua is a rare disorder which is very challenging to manage by an epilepsy specialist, more so by a geriatrician. The decision to live with this partial seizure versus sedation to abort it is a difficult one, and the underlying principle is the quality of life for the patient. For many residents, the nursing home is their home. Thus improving or maintaining their quality of life by giving them all the necessary support to live with their medical problem is very important. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.
Estimating Total Acetaminophen Burden in LTC Residents with Diabetes Presenting Author: Dean Gianarkis, MS, PharmD, Pfizer Author(s): Dean Gianarkis, MS, PharmD; and Robert Fusco, BScPh
JAMDA – March 2010
Introduction/Objective: In June of 2009 the FDA held an advisory committee meeting to address problems associated with acetaminophen (APAP) toxicity. Several options have been proposed to mitigate these problems. The objective of this research was to determine total APAP dose burden from stand-alone orders and combination analgesics in residents with diabetes. Design/Methodology: The pharmacy computer system was used to identify residents with diabetes who were receiving APAP and APAP-containing analgesics over a 6-month period from January to June 2009. No other APAP-containing products (e.g. cough/cold preparations) were included in the analysis. The sample was obtained from 17 randomly selected longterm care facilities in New Jersey. Information including dose and instructions for use were collected by pharmacy students using paper data collection forms. All information was entered into Microsoft Access which was used to perform the analysis. Results: There were 84/101 (83%) residents who had at least one order for an analgesic agent during the study period. Approximately two-thirds (64%) had a stand-alone order for APAP. The mean daily dose was 3,315mg and 89% (58/65) were designated ‘‘as needed.’’ However, 35% (23/65) of residents also had an order for a combination analgesic containing APAP (mean dose 1,870 1,068mg). Similar to APAP, most (81%) were prescribed ‘‘as needed.’’ Four residents (17%) had an order for a second APAP-containing analgesic. Overall, the mean total daily APAP burden in residents prescribed APAP and an APAP-containing analgesic was 5,248 1,334mg (range 2,975-8,450mg). 91% could potentially surpass the current 4gram maximum daily dose (MDD) for APAP and all are in excess of the 2.6gram limit proposed by the FDA. Conclusion/Discussion: Although frequently dosed on an ‘‘as needed’’ basis, APAP and APAP-containing analgesics are often prescribed together and exceed MDD limitations. While none of the residents had standing orders greater than 4grams, medication administration records are needed to determine the actual APAP burden. The fact that APAP in prescription analgesics may be difficult to identify has been recognized by the FDA. Education of facility staff is needed to avoid APAP toxicity in not only residents with diabetes but all residents. Disclosures: Dean Gianarkis, MS, PharmD is a salaried employee of Pfizer Inc. Robert Fusco, BScPh has stated there are no disclosures to be made that are pertinent to this abstract.
Evaluating the Impact of Health Care Providers’ Knowledge, Attitudes, and Behavior on MOLST Implementation in Long Term Care Facilities Presenting Author: Hieu Vo, MD, North Shore-LIJ Health System Author(s): Hieu Vo, MD, Howard Guzik, MD, Christian Nouryan, MA, Charito Patel, RN, Renee Pekmezaris, PhD; and Gisele Wolf-Klein, MD Introduction/Objective: In 2006, the New York Department of Health approved the MOLST form, as an actionable medical order to transition patients through all health care settings statewide. We evaluated the impact of health care providers on MOLST implementation in long term care facilities. Design/Methodology: Anonymous survey of physicians, nurses and social workers in long term care facilities with high and low rates of MOLST implementation. Results: We collected 76 surveys in the three institutions with highest penetration of MOLST implementation (44%-76%) and 44 in the three with lowest penetration (0-5%) within the nursing home affiliates of North Shore-LIJ Health System. Analysis of demographic data, including age, gender, ethnicity, religion, professional background, and year of employment revealed no statistical differences between high and low performing facilities. There were also no differences in the annual reported frequency of requests by patients and families to complete a MOLST form (1.06 vs. 88, respectively), the number of interactions with patients to discuss advance directives (1.0 vs. 0.76) or with families (1.14 vs. 0.93) and the number of requests to honor a MOLST (1.11 vs. 1.21). Indeed, both groups had been personally involved with a clinical situation where MOLST avoided unnecessary hospitalizations (55% vs. 56%). Both groups believed that the MOLST forms needed to be signed by a physician in order to be valid (81% and 90%). In addition, 37% of high penetration group versus 16% of low penetration knew that the
POSTER ABSTRACTS
MOLST form does not have to be pink to be valid. When comparing high and low penetration groups, 86% versus 38%, respectively, agreed that all long term care residents should have a MOLST form (p \ .0001) and 44% versus 5% agreed that residents with MOLST forms had better pain management (p \ .0001). A third (38%) of the high penetration group versus 16% of the low penetration knew that the MOLST form does not have to be pink to be valid (p \ .03). Finally, 52% versus 35% selected physicians as most likely team members to be involved in End of Life discussions(p 5 .02). Conclusion/Discussion: There is a clear correlation between level of knowledge and attitudes regarding the importance of advance directive execution and MOLST and actual utilization of advance directives. In addition, our study suggests that high performing facilities have a stronger belief that physicians need to take an active part in completing MOLST documents in order to effectively implement advance directives for residents of long-term care facilities. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.
Health Care Employees’ Knowledge and Awareness of Pressure Ulcers in Hospitals and Long-Term Care Facilities Presenting Author: Sarika Sharma, MD, North Shore-LIJ Health System Author(s): Sarika Sharma, MD, Muhammad S. Ashraf, MD, Gabriel El-Kass, MD, Jesse Kuniyil, MD, Betina Louis, MD, Ann Eichorn, MPH, Roshan Hussain, MPH, Charles Cal, RN, MSN, MBA, Yosef Dlugacz, PhD, Renee Pekmezaris, PhD, Barbara Tommasulo, MD; and Gisele Wolf-Klein, MD Introduction/Objective: Using the Centers for Medicare and Medicaid Services pressure ulcers guidelines (CMS, 2008), we designed a study to examine attitudes and knowledge of pressure ulcers among health care personnel in hospitals and long-term care facilities. Design/Methodology: Anonymous survey of physicians, nurses, nursing assistants and nurses aids, in 4 hospitals and 5 nursing homes. Descriptive statistics and Chi-square analysis were used to test significant differences between hospital and nursing home employees. Results: Of the 520 surveys collected, 40% were from hospitals and 52.7% from long-term care. Overall, only a quarter of hospital (28%) or long-term care employees (25.7%) reported being aware of current CMS guidelines. Among those employees, nursing home nurses (68.5%) and physicians (54.6%) were significantly more knowledgeable than hospital employees (48.3% nurses, p 5 0.07; 44% physicians, p 5 0.52) of new reimbursement incentives for institutions with lower ulcer rates. More hospital employees knew that pressure is not the only cause of ulcer formation (72% v.60%, p 5 0.03), that constant low pressure applied for long time is a risk factor (53.2% v. 42.5%, p 5 0.0004), that massaging skin is not preventive (61% v. 48%, p 5 .0008), that documentation should begin at arrival in hospital (87.6% v. 72.4% p 5 0.001), or nursing facilities, (89.7% v. 76.05%, p 5 0.0007), and that cost of treatment is greater than prevention (77% v. 63%, p 5 .006). However, they were significantly more likely to omit skin assessment in patients on ventilators (68.8% v 20.1%, p \ 0.0001), comatose (62.8% v 15.9%, p \ 0.0001), morbidly obese (71.7% v 18.9%, p \ 0.0001), with spine immobilization (74.9% v 19.5%, p \ 0.0001), aggressive (76.7% v 23.4%, p \ 0.0001), on contact precautions (60.4% v 14.2%. p \ 0.0001) or on palliative care (67.0% v 18.9%, p \ 0.0001). Other barriers in hospital employees included another physician (74.6% v 19.9%, p \ 0.0001) or nurse (75.5% v 26.3%, p \ 0.0001) having already documented on same day, lack of assistance in positioning patients (72.1% v 19.2%, p \ 0.0001), lack of awareness (70.5% v 14.9%, p \ 0.0001), time (75.3% v 21.0%, p \ 0.0001) or expertise (59.2% v 11.8%, p \ 0.0001), perceptions that other conditions were more important (72.3% v 17.6%, p \ 0.0001), or that ulcer management would not change course (62.5% v 14.9%, p \ 0.0001). Conclusion/Discussion: Though hospital staff appears more knowledgeable than nursing home employees with regards to etiology and treatment of pressure ulcers, clinical practice of routine skin assessment is considerably less consistent in hospital than in long term care facilities.
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End of Life Care in the Nursing Home Setting Presenting Author: Petra Flock, MD, MSc, CMD, University of Massachusetts Author(s): Petra Flock, MD, MSc, CMD; and Jill M. Terrien, PhD, APN-BC Introduction/Objective: For this study a cross-sectional mailed survey to explore next of kin’s perspectives on end-of-life care in the nursing home setting was developed. It tested the feasibility of the method in terms of recruitment and response rate, and pilot tested the survey instrument. Decedents who received Hospice services in addition to traditional nursing home care were compared to those who received traditional care alone. Design/Methodology: A postal survey was designed and tested with next of kin of nursing home decedents of three nursing homes, who died between 4/1/07 to 4/1/08. Data collected included: demographics, communication, pain and symptom management, advance directives, hospice utilization and responses to two qualitative questions. Quantitative data was analyzed
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using frequencies, percentages and Pearson chi square statistics. Qualitative data was analyzed by themes. Results: The mailed survey yielded a 70% response rate. Symptom burden was high with more than 70% experiencing pain, agitation, and anxiety; 60% had shortness of breath and depression. Over 88% of next of kin reported good to excellent symptom control, 91% were kept well-informed about the decedent’s condition, and more than 90% were satisfied with medical and nursing care. The vast majority (89%) had advance directives in place. There was no difference in symptom control, communication, level of care or advance directives between the Hospice and traditional care groups. Conclusion/Discussion: Postal survey is a feasible method to explore end of life care in the nursing home setting. In this study, pain, symptom management and communication at the end-of-life in nursing homes was better than nationally reported data 1, 2, 3 irrespective of how that care was provided. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.
Epilepsia Partialis Continua not Amenable to Medical Therapy Presenting Author: Kofi Quist, MD, Montefiore Medical Center Author(s): Kofi K. Quist, MD; and Wanda Horn, MD Introduction/Objective: Epilepsia partialis continua is a type of focal motor epilepsy characterized by persistent clonic movements of a muscle group with repetition at fairly regular intervals every few seconds, continuing for hours, days, weeks, or months without generalization. Design/Methodology: Case. Results: A 78 year old female nursing home resident with past medical history of epilepsy secondary to a right parietal arteriovenous malformation was admitted with left upper extremity clonic movements. Patient had dementia and at baseline was verbal, bedbound, non-ambulatory, and dependant in activities of daily living. Although she was frequently not compliant with her regular epilepsy medications due to paranoid ideations, she had not had a seizure for a significant period of time. Her current medications were phenobarbital and levetiracetam. Physical examination revealed an elderly female who was awake with fluent speech, oriented to person only and with a flat affect. Neurological examination was significant for left facial droop and left hemiparesis. There was increased muscle tone with regular tonic-clonic movements of the left upper extremity. Power was 2/5 on left side and normal on right side in both upper and lower extremities. Sensation was grossly intact to light touch and pinprick. Laboratory data did not reveal any electrolyte abnormalities, but showed subtherapeutic serum level of phenobarbital, and leucocytosis which was attributed to sinusitis. Head CT showed right fronto-parietal encephalomalacia. Patient was evaluated by an epilepsy specialist with an impression of focal seizures. Electroencephalogram was consistent with epilepsia partialis continua. She did not respond to multiple trials of anti-epileptic medications including dilantin, oxcarbazepine, levetiracetam and phenobarbital over a period of seventeen days. The involuntary left upper extremity movements only decreased in intensity when she was heavily sedated with lorazepam but did not completely resolve. After several meetings between the epilepsy specialist, geriatric team and patient’s family, a decision was made to discharge her back to the nursing home with continued left upper extremity clonic movements. Conclusion/Discussion: Epilepsia partialis continua is a rare disorder which is very challenging to manage by an epilepsy specialist, more so by a geriatrician. The decision to live with this partial seizure versus sedation to abort it is a difficult one, and the underlying principle is the quality of life for the patient. For many residents, the nursing home is their home. Thus improving or maintaining their quality of life by giving them all the necessary support to live with their medical problem is very important. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.
Estimating Total Acetaminophen Burden in LTC Residents with Diabetes Presenting Author: Dean Gianarkis, MS, PharmD, Pfizer Author(s): Dean Gianarkis, MS, PharmD; and Robert Fusco, BScPh
JAMDA – March 2010
Introduction/Objective: In June of 2009 the FDA held an advisory committee meeting to address problems associated with acetaminophen (APAP) toxicity. Several options have been proposed to mitigate these problems. The objective of this research was to determine total APAP dose burden from stand-alone orders and combination analgesics in residents with diabetes. Design/Methodology: The pharmacy computer system was used to identify residents with diabetes who were receiving APAP and APAP-containing analgesics over a 6-month period from January to June 2009. No other APAP-containing products (e.g. cough/cold preparations) were included in the analysis. The sample was obtained from 17 randomly selected longterm care facilities in New Jersey. Information including dose and instructions for use were collected by pharmacy students using paper data collection forms. All information was entered into Microsoft Access which was used to perform the analysis. Results: There were 84/101 (83%) residents who had at least one order for an analgesic agent during the study period. Approximately two-thirds (64%) had a stand-alone order for APAP. The mean daily dose was 3,315mg and 89% (58/65) were designated ‘‘as needed.’’ However, 35% (23/65) of residents also had an order for a combination analgesic containing APAP (mean dose 1,870 1,068mg). Similar to APAP, most (81%) were prescribed ‘‘as needed.’’ Four residents (17%) had an order for a second APAP-containing analgesic. Overall, the mean total daily APAP burden in residents prescribed APAP and an APAP-containing analgesic was 5,248 1,334mg (range 2,975-8,450mg). 91% could potentially surpass the current 4gram maximum daily dose (MDD) for APAP and all are in excess of the 2.6gram limit proposed by the FDA. Conclusion/Discussion: Although frequently dosed on an ‘‘as needed’’ basis, APAP and APAP-containing analgesics are often prescribed together and exceed MDD limitations. While none of the residents had standing orders greater than 4grams, medication administration records are needed to determine the actual APAP burden. The fact that APAP in prescription analgesics may be difficult to identify has been recognized by the FDA. Education of facility staff is needed to avoid APAP toxicity in not only residents with diabetes but all residents. Disclosures: Dean Gianarkis, MS, PharmD is a salaried employee of Pfizer Inc. Robert Fusco, BScPh has stated there are no disclosures to be made that are pertinent to this abstract.
Evaluating the Impact of Health Care Providers’ Knowledge, Attitudes, and Behavior on MOLST Implementation in Long Term Care Facilities Presenting Author: Hieu Vo, MD, North Shore-LIJ Health System Author(s): Hieu Vo, MD, Howard Guzik, MD, Christian Nouryan, MA, Charito Patel, RN, Renee Pekmezaris, PhD; and Gisele Wolf-Klein, MD Introduction/Objective: In 2006, the New York Department of Health approved the MOLST form, as an actionable medical order to transition patients through all health care settings statewide. We evaluated the impact of health care providers on MOLST implementation in long term care facilities. Design/Methodology: Anonymous survey of physicians, nurses and social workers in long term care facilities with high and low rates of MOLST implementation. Results: We collected 76 surveys in the three institutions with highest penetration of MOLST implementation (44%-76%) and 44 in the three with lowest penetration (0-5%) within the nursing home affiliates of North Shore-LIJ Health System. Analysis of demographic data, including age, gender, ethnicity, religion, professional background, and year of employment revealed no statistical differences between high and low performing facilities. There were also no differences in the annual reported frequency of requests by patients and families to complete a MOLST form (1.06 vs. 88, respectively), the number of interactions with patients to discuss advance directives (1.0 vs. 0.76) or with families (1.14 vs. 0.93) and the number of requests to honor a MOLST (1.11 vs. 1.21). Indeed, both groups had been personally involved with a clinical situation where MOLST avoided unnecessary hospitalizations (55% vs. 56%). Both groups believed that the MOLST forms needed to be signed by a physician in order to be valid (81% and 90%). In addition, 37% of high penetration group versus 16% of low penetration knew that the
POSTER ABSTRACTS
MOLST form does not have to be pink to be valid. When comparing high and low penetration groups, 86% versus 38%, respectively, agreed that all long term care residents should have a MOLST form (p \ .0001) and 44% versus 5% agreed that residents with MOLST forms had better pain management (p \ .0001). A third (38%) of the high penetration group versus 16% of the low penetration knew that the MOLST form does not have to be pink to be valid (p \ .03). Finally, 52% versus 35% selected physicians as most likely team members to be involved in End of Life discussions(p 5 .02). Conclusion/Discussion: There is a clear correlation between level of knowledge and attitudes regarding the importance of advance directive execution and MOLST and actual utilization of advance directives. In addition, our study suggests that high performing facilities have a stronger belief that physicians need to take an active part in completing MOLST documents in order to effectively implement advance directives for residents of long-term care facilities. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.
Health Care Employees’ Knowledge and Awareness of Pressure Ulcers in Hospitals and Long-Term Care Facilities Presenting Author: Sarika Sharma, MD, North Shore-LIJ Health System Author(s): Sarika Sharma, MD, Muhammad S. Ashraf, MD, Gabriel El-Kass, MD, Jesse Kuniyil, MD, Betina Louis, MD, Ann Eichorn, MPH, Roshan Hussain, MPH, Charles Cal, RN, MSN, MBA, Yosef Dlugacz, PhD, Renee Pekmezaris, PhD, Barbara Tommasulo, MD; and Gisele Wolf-Klein, MD Introduction/Objective: Using the Centers for Medicare and Medicaid Services pressure ulcers guidelines (CMS, 2008), we designed a study to examine attitudes and knowledge of pressure ulcers among health care personnel in hospitals and long-term care facilities. Design/Methodology: Anonymous survey of physicians, nurses, nursing assistants and nurses aids, in 4 hospitals and 5 nursing homes. Descriptive statistics and Chi-square analysis were used to test significant differences between hospital and nursing home employees. Results: Of the 520 surveys collected, 40% were from hospitals and 52.7% from long-term care. Overall, only a quarter of hospital (28%) or long-term care employees (25.7%) reported being aware of current CMS guidelines. Among those employees, nursing home nurses (68.5%) and physicians (54.6%) were significantly more knowledgeable than hospital employees (48.3% nurses, p 5 0.07; 44% physicians, p 5 0.52) of new reimbursement incentives for institutions with lower ulcer rates. More hospital employees knew that pressure is not the only cause of ulcer formation (72% v.60%, p 5 0.03), that constant low pressure applied for long time is a risk factor (53.2% v. 42.5%, p 5 0.0004), that massaging skin is not preventive (61% v. 48%, p 5 .0008), that documentation should begin at arrival in hospital (87.6% v. 72.4% p 5 0.001), or nursing facilities, (89.7% v. 76.05%, p 5 0.0007), and that cost of treatment is greater than prevention (77% v. 63%, p 5 .006). However, they were significantly more likely to omit skin assessment in patients on ventilators (68.8% v 20.1%, p \ 0.0001), comatose (62.8% v 15.9%, p \ 0.0001), morbidly obese (71.7% v 18.9%, p \ 0.0001), with spine immobilization (74.9% v 19.5%, p \ 0.0001), aggressive (76.7% v 23.4%, p \ 0.0001), on contact precautions (60.4% v 14.2%. p \ 0.0001) or on palliative care (67.0% v 18.9%, p \ 0.0001). Other barriers in hospital employees included another physician (74.6% v 19.9%, p \ 0.0001) or nurse (75.5% v 26.3%, p \ 0.0001) having already documented on same day, lack of assistance in positioning patients (72.1% v 19.2%, p \ 0.0001), lack of awareness (70.5% v 14.9%, p \ 0.0001), time (75.3% v 21.0%, p \ 0.0001) or expertise (59.2% v 11.8%, p \ 0.0001), perceptions that other conditions were more important (72.3% v 17.6%, p \ 0.0001), or that ulcer management would not change course (62.5% v 14.9%, p \ 0.0001). Conclusion/Discussion: Though hospital staff appears more knowledgeable than nursing home employees with regards to etiology and treatment of pressure ulcers, clinical practice of routine skin assessment is considerably less consistent in hospital than in long term care facilities.
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